Field study of the efficacy of three types of nose net for the treatment of headshaking in horses

Thirty-six owners of seasonally headshaking horses took part in a trial to compare the effectiveness of three types of nose net, a traditional cylindrical net (full net) and two forms of larger mesh nets which cover only the nostrils and dorsorostral muzzle (half nets). Baseline data relating to the overall severity of the problem and 18 specific behaviours describing the nature of the problem were recorded on a check sheet by the owners. A within-subjects repeated measures design experiment, with each net used for a week before reassessment, was then used to assess the effect of the nets on the headshaking problem. Approximately 75 per cent of owners reported some overall improvement with each net; around 60 per cent recorded a 50 per cent or greater improvement and 30 per cent a 70 per cent or greater improvement. The nets significantly reduced the overall headshaking score and the following specific behaviours: up-and-down headshaking, nose flipping, acting as if a bee had flown up the nose, shaking at exercise, shaking when excited, shaking in bright sunlight or in windy conditions (P < 0.0001), striking at the face, shaking at night, rubbing the nose when moving, rubbing the nose on objects, sneezing, shaking in the rain and shaking indoors (P < 0.05). There was no evidence of a significant effect on side-to-side headshaking, shaking at rest or rubbing the nose when stationary, but the effect on snorting was uncertain. There were few significant differences between the nets, but the half nets were reported to be significantly better at controlling 'bee up the nose' behaviour. Horses more than 10 years old were reportedly less likely to show a 50 per cent or greater improvement in 'nose flipping' and 'headshaking at exercise.     

Owner survey of headshaking in horses

OBJECTIVE: To determine signalment, history, clinical signs, duration, seasonality, and response to various treatments reported by owners for headshaking in horses. DESIGN: Owner survey. ANIMALS: 109 horses with headshaking. PROCEDURE: Owners of affected horses completed a survey questionnaire. RESULTS: 78 affected horses were geldings, 29 were mares, and 2 were stallions. Mean age of onset was 9 years. Headshaking in 64 horses had a seasonal component, and for most horses, headshaking began in spring and ceased in late summer or fall. The most common clinical signs were shaking the head in a vertical plane, acting like an insect was flying up the nostril, snorting excessively, rubbing the muzzle on objects, having an anxious expression while headshaking, worsening of clinical signs with exposure to sunlight, and improvement of clinical signs at night. Treatment with antihistamines, nonsteroidal anti-inflammatory drugs, corticosteroids, antimicrobials, fly control, chiropractic, and acupuncture had limited success. Sixty-one horses had been treated with cyproheptadine; 43 had moderate to substantial improvement. CONCLUSIONS AND CLINICAL RELEVANCE: Headshaking may have many causes. A large subset of horses have similar clinical signs including shaking the head in a vertical plane, acting as if an insect were flying up the nostrils, and rubbing the muzzle on objects. Seasonality and worsening of clinical signs with exposure to light are also common features of this syndrome. Geldings and Thoroughbreds appear to be overrepresented. Cyproheptadine treatment was beneficial in more than two thirds of treated horses.     

A randomised,blinded, crossover study to assess the efficacy of a feed supplement in alleviating the clinical signs of headshaking in 32 horses

Reasons for performing study: Feed supplements are commonly used by owners to alleviate headshaking; however, randomised, controlled trials are required to assess their efficacy. Objective: To determine the efficacy of a feed supplement for alleviation of the clinical signs of headshaking using a randomised, blinded, placebo‐controlled trial. Methods: Using a crossover design, 44 horses previously diagnosed with chronic idiopathic headshaking received both the supplement and a matching placebo per os for 28 days with a washout period between of 14 days. Video recordings were taken at rest and exercise prior to the study and at the end of both periods of treatment. The degree of headshaking was assessed in a blinded, randomised manner by 2 veterinary surgeons. At the same time points, owners completed a questionnaire to assess the severity of headshaking signs. A Wilcoxon signed rank test was used to compare the scores while on supplement and placebo. Results: Using the video assessments, there was no significant difference between scores while on supplement compared with placebo (P = 0.7). Using the questionnaire responses, there was no significant difference between scores for any activity when the placebo and the supplement were compared with each other. However, owners reported significant improvement during all activities for both placebo and supplement compared with pretreatment scores. Conclusions and potential relevance: The supplement offered no benefit over a placebo in alleviating the clinical signs of headshaking. There appeared to be a significant proxy placebo effect when the outcome was based on subjective owner perception of clinical signs. This study demonstrated no beneficial effect of this supplement on the clinical signs of headshaking. The study did show a significant placebo effect, thereby highlighting the necessity of properly conducted, randomised controlled trials, with blinding, to assess true treatment effects in trials in animals.     

Fungal sinusitis resulting in suspected trigeminal neuropathy as a cause of headshaking in five horses

Primary fungal sinusitis was identified in 5 horses displaying signs of headshaking. All 5 horses had fungal plaques adhered to the infraorbital canal (IOC). Headshaking signs were exhibited by 3 horses prior to treatment and 2 horses after treatment. Standing computed tomography (CT) identified erosion of the IOC in the 2 cases in which it was performed. Fungal culture and PCR identified 3 species of fungi, Rhizomucor pusillus, Scedosporium apiospermum and Aspergillus nidulans which have not previously been described as a cause of sinusitis in horses. Surgical debridement followed by topical antifungal therapy was used in all 5 horses. Recurrence of the fungal plaques in 4 horses necessitated further treatment. The headshaking signs and nasal discharge resolved in 3 horses allowing a return to their previous use. Two horses developed persistent headshaking signs despite multiple treatments. Primary fungal sinusitis should be considered as a cause of headshaking signs in horses, due to a suspected trigeminal neuropathy. Computed tomography is valuable in identifying erosion of the IOC which is not identified with conventional radiography. Three out of the 5 cases were treated successfully but permanent resolution of the fungal infection is difficult to achieve once the bone overlying the infraorbital nerve has been eroded.     

An epidemiological study of summer eczema in Icelandic horses in Norway

A survey of summer eczema was conducted on 391 Icelandic horses in Norway. The study showed a prevalence of summer eczema of 17.6 per cent in the horses investigated. Icelandic horses born in Norway where shown to be less affected with summer eczema than imported horses, 8.2 per cent and 26.9 per cent respectively (P less than 0.001). There was no difference in the prevalence of summer eczema relative to gender or colour of the horse. The number of horses affected with summer eczema rose with increasing age and the number of years which had elapsed since importation. On average, Icelandic horses born in Norway developed summer eczema at the age of 5.3 years. The onset of disease for imported horses was, on average, 4.1 years after importation. The study also revealed that a significantly greater number of horses imported from Iceland to Norway during the period October to April, which has a minimal or low activity of insects (32.3 per cent), had developed summer eczema, compared with horses imported during the period May to September, when insects are more active (16.7 per cent), (P = 0.044). Horses with summer eczema were shown to be significantly more affected by respiratory disease than non-affected horses (P = 0.0086). The most common sites and clinical signs of summer eczema are also described.     

Use of a gonadotrophin-releasing hormone vaccine in headshaking horses

The aim of this study was to investigate the use of a gonadotrophin-releasing hormone (GnRH) vaccine in the treatment of headshaking in horses. Fifteen geldings received two doses of the GnRH vaccine four weeks apart. Serum was collected before and after vaccination to measure concentrations of luteinising hormone (LH) (10 horses) and follicle-stimulating hormone (FSH) (six horses). Owners recorded the frequency of seven common headshaking behaviours using a visual analogue scale (VAS) before vaccination and at two, four, eight, 12, 16 and 20 weeks after vaccination. Serum LH (P=0.008) and FSH (P=0.03) concentrations decreased significantly following vaccination. Although approximately one-third of the owners reported a subjective improvement in headshaking, serial scoring did not indicate a reduction in headshaking behaviours following vaccination with a commercial GnRH vaccine. Vaccination reactions were observed in four of 15 horses (27 per cent), including one case of severe, presumed immune-mediated, myositis.     

Observations on headshaking in the horse

The clinical records of 100 cases of headshaking in horses were reviewed. Possible causes of the abnormal behaviour were identified in 11 animals; these included ear mite infestation, otitis interna, cranial nerve dysfunction, cervical injury, ocular disease, guttural pouch mycosis, dental periapical osteitis and suspected vasomotor rhinitis. However, in only two of these could it be shown that correction of the abnormality led to elimination of the headshaking. The additional clinical signs exhibited by the other idiopathic cases of headshaking included evidence of nasal irritation, sneezing and snorting, nasal discharge, coughing and excessive lacrimation. Many of these horses also showed a marked seasonal pattern with respect to the onset of the disease and the recurrence of signs in subsequent years. The clinical presentation of idiopathic headshakers and the seasonal incidence of the signs closely resemble allergic rhinitis in man.     

Overview of the Current Situation in a Sample of Headshakers and Owner Assessment of Effective Therapeutic Measures Used in Germany

Equine headshaking syndrome is a problematic behavior that has been described in literature for more than 100 years. The signs of headshaking syndrome appear frequently and violently so that riding the horse can be dangerous. The aim of this research was to gain an overview of the underlying causes of equine headshaking syndrome to identify effective treatment options, reduce the distress of horses and, in a second step, potentially improve therapeutic possibilities for horse owners and veterinarians. Most studies on prevalence originate from Anglo-American countries, so this research was to provide an overview of German horses; therefore, an online survey was designed by experts in the field (researchers and veterinarians) and answered by German horse owners. Questionnaires were pretested by a small group of horse owners (n = 5) and redesigned accordingly. The final questionnaire consisted of 27 questions, which were divided into seven open questions with an associated text field and 20 multiple-choice questions (Supplementary Material 1). For some of the multiple-choice questions, multiple answers were permitted. In total, 163 completed questionnaires were obtained from owners of headshaking horses (n_total = 163). Gender distribution of the horses resulted in 64.4% geldings, 33.7% mares, and 1.8% stallions. Most horses were German warmbloods (55.4%). The average age was 12.7 years (with a wide range of 5 to 34 years). The vertical movement of the head was the most frequently mentioned symptom in 75.5% of the evaluated horses. In 18.4% of the cases, the horse owners identified stress as the main trigger for headshaking. Furthermore, 18.4% claimed that their horses suffered from additional stereotypical behavior. The percentages do not refer to the same horses here. 11.0% of the participants in this study tried scientifically evaluated therapies such as surgical therapy (1.2%) or medical treatment (9.8%). In addition, 54.0% of the owners utilized a nose cover to reduce the symptoms of the headshaking syndrome. A high percentage of 84.0% used alternative therapies such as physiotherapy (31.9%), change of equipment (22.7%), or change of riding style (29.4%). Overall, this study provides a useful overview of causes and effective therapies.     

Entrapment of the small intestine in the epiploic foramen in horses: a retrospective analysis of 71 cases recorded between 1991 and 2001

The clinical features of 71 cases in 70 horses in which part of the small intestine became entrapped in the epiploic foramen are described. The horses' sex, age and breed, the month during which they were affected, and whether they exhibited stereotypic behaviour were compared with the same variables in 1279 horses which suffered other types of surgical colic during the same period. Thoroughbred and thoroughbred cross horses were over-represented among the 70 affected horses. There was no age or sex predilection. Fifty-five (77.5 per cent) of the cases occurred between October and March and 15 (21.1 per cent) occurred in January. The cases were significantly more likely to have a history of crib-biting/windsucking than the control group (odds ratio 7.9, 95 per cent confidence interval 4.1 to 15.3). The condition had recurred in two of the horses. Fifty-eight (81.7 per cent) recovered from surgery and 49 (69 per cent) survived until they were discharged from hospital. The median survival time of 31 of the affected horses discharged from the hospital was 700 days, whereas 417 horses with other types of surgical colic had a median survival time in excess of 1931 days.     

Electroacupuncture as an additional treatment for headshaking in six horses

Some success has been demonstrated using percutaneous electrical nerve stimulation (PENS) to treat trigeminal-mediated headshaking (TMHS) in horses. The aim of this study is to determine whether electroacupuncture (EA) can provide similar remission from the pain of this debilitating condition. EA is less invasive than PENS and can be carried out in the stable yard without the need for a hospital setting and expensive equipment. Six horses and ponies showing clinical signs of headshaking were treated with electroacupuncture of the infraorbital nerve under light sedation. The nerve was stimulated with alternating 2 and 80 Hz frequencies for a period of 25 min with the current adjusted so that there was visible twitching of the nostrils and/or lips. Follow-up treatments were given when the signs recurred or 4–7 days later if there was no initial response. The procedure was well tolerated by all the horses. Once a response was achieved, the period of remission often increased with subsequent treatments. Median remission time for the first treatment was 5.5 days (mean 7.6 days, range 0–13 days, n = 6). second treatment 8.5 days (mean 10.6 days, range 7–21 days, n = 6), third treatment 18 days (mean 28.8 days, range 6–71 days, n = 6), fourth treatment 47.5 days (mean 10 weeks, range 11 days–23 weeks, n = 6), fifth treatment 13 weeks 5 days (mean 18 weeks 5 days, range 5 weeks–46 weeks, n = 5), sixth treatment 24 days (mean 26 days, range 13–41 days, n = 3). The three horses that started treatment in 2015 received a single treatment in April or May of 2016 and were still asymptomatic at the end of the study period in October 2016. It was concluded that EA of the infraorbital nerve is an effective and well-tolerated treatment for the management of horses considered to be experiencing trigeminal-mediated headshaking.     

Arthroscopic removal of osteochondral fragments of the palmar/plantar aspect of the metacarpo/metatarsophalangeal joints

This paper presents the results of arthroscopic surgery in 42 Standardbred trotters and three Finnish horses. Forty-five horses were operated on. The age range was one to seven years; 73 per cent of the horses were three years old or younger. Horses showed a variety of clinical signs ranging from moderate to severe lameness at slow speeds, to obscure lameness manifesting only at high speeds. Synovial effusion of the fetlock joint was rare. In this series, 44 horses that had Type I fragments and one horse that had Type III fragments were operated on. Of the 45 horses operated on, 23 (51 per cent) returned to speed training in three months and 41 (91 per cent) returned to speed training in six months. Three of 45 (6 per cent) were lame three months after the surgery when the trainer attempted to start speed training. One of those was sound six months after the operation. The remaining two (4 per cent) stayed lame due to a lesion in the affected joint. Two of 45 (4 per cent) discontinued training for other reasons. The horse with Type III fragments returned to speed training in three months.     

Comparative behaviour studies in horses infested with flying insects treated with insecticide or repellent substances

The aim of this study was to estimate the effects of flying insects (Order Diptera) on the behaviour of grazing horses in relation to the use of insecticide and repellent substances. The investigations were done between June and August in 2008 in 3 periods of 7 days each. As insecticide and repellent two substances were used: "Well-care emulsion" (Co. Essex Tierarznei, München, GER) containing Permethrin and "Bremsen-Frei-Plus" (Co. Dr. Schaette AG, Bad Waldsee, GER) based on etheric oils. Both groups were compared with a non treated control group in a crossover-design. Each group (n = 3-5) was used alternately as control and treatment group. Several climate parameters were taken during the study. Furthermore, the number of insects per animal was estimated at certain times. Once per observation period insects were caught using Malaise traps and differentiated by species. The proportion of horse relevant species of the genera Diptera, especially Culex pipiens and Musca autumnalis, caught was 9% on an average. There was no correlation between the number of Tabanidae caught in the Malaise traps and the number observed near by the horses. Behaviour parameters like tailswishing, headshaking, stamping, skintwitching, snapping at the body, and moving were observed more frequently with increasing insect infestation. When horses were infested with a high number of flying insects, feeding activity was significant lower, whereas locomotion activity was significant higher. Both substances had positive effects for about 50 hours after application with no apparent difference between the substances. However, a lower frequency of headshaking and tailswishing could be observed in the Permethrin treated horses.     

Fever of unknown origin in the horse: a review of 63 cases

Fever of unknown origin (FUO) is a syndrome characterised by prolonged, unexplained fever associated with non-specific signs of illness such as lethargy, inappetence and weight loss. This paper reviews the details of 63 horses affected by FUO. The cause was found to be infection in 43 per cent of the cases, neoplasia in 22 per cent, immune-mediated diseases in 6.5 per cent and miscellaneous diseases in 19 per cent; the cause remained undiagnosed in 9.5 per cent.     

Field study of the prevalence of lameness in horses with back problems

A population of 805 horses (70 per cent dressage, 20 per cent show jumpers and 10 per cent trotters) with orthopaedic problems was examined for signs of lameness and back problems, irrespective of their original complaints. In the horses with a back problem the prevalence of lameness was 74 per cent, and back problems were diagnosed in 32 per cent of the lame horses. These percentages were significantly higher than those recorded in a control population of 399 horses, of which 20 per cent were lame and 12 per cent had back problems. In the group of horses with orthopaedic problems there was a strong association between lameness and back problems and, in particular, there was a high prevalence of lameness among the horses with back problems.     

Prevalence and some clinical characteristics of equine cheek teeth diastemata in 471 horses examined in a UK first-opinion equine practice (2008 to 2009)

Cheek teeth (CT) diastemata are now recognised as a clinically significant equine disorder, but their prevalence in the general equine population is unknown. There is also limited information on the signalment of affected horses; the more commonly affected Triadan sites; and the shape and clinical characteristics of CT diastemata. During the 12-month study period (2008 to 2009), standardised records were obtained during routine dental examinations performed by five veterinarians in a first-opinion equine practice. Cheek teeth diastemata were identified in 49.9 per cent of all horses (n=471) of mean age 11 years (range one to 30 years), with 83.5 per cent of all diastemata affecting mandibular CT and 16.5 per cent affecting maxillary CT. The mean number of diastemata per case was 1.7 (range one to 20) and the mandibular 07 to 08 position was most commonly affected. Valve diastemata were more common (72.1 per cent prevalence) than open diastemata (27.9 per cent). Food trapping was present in 91.4 per cent of diastemata, with gingivitis and periodontal pockets adjacent to 34.2 per cent and 43.7 per cent, respectively. Halitosis was present in 45.5 per cent of affected horses. There was an age-related increase in both the prevalence of diastemata, and in the numbers of diastemata per affected horse, and horses over 15 years old had a significantly increased proportion of open diastemata.     

Incidence of exertional rhabdomyolysis in polo horses in the USA and the United Kingdom in the 1999/2000 season

A questionnaire was used to determine the incidence of exertional rhabdomyolysis and the factors that might have contributed to its occurrence among 423 polo horses in 11 yards. The yards were selected at random, six of them with 111 horses, in north-eastern USA, and five with 312 horses in south-east England. During the 1999/2000 season the incidence of the condition was 7.3 per cent (9 per cent in the USA and 6.7 per cent in England). The incidence in mares was similar in the two countries, 8.4 per cent in the USA and 8.0 per cent in England, but the incidence in geldings in the USA (10 per cent) was much higher than in England (1.5 per cent). A more excitable than average temperament was reported in 71 per cent of the horses with the condition, and most cases occurred after a game (chukka) in which the horse was perceived to be not fit enough for the level of play demanded. Sixty-four per cent of the cases occurred early in the season and on average each episode resulted in the loss of 7.6 training days.     

Retrospective study of the clinical features of limb cellulitis in 63 horses

A retrospective study of 63 horses diagnosed with limb cellulitis between 1994 and 2005 was conducted. They all had an acute onset of painful, generalised limb swelling, and a clinical diagnosis of limb cellulitis was made by the attending clinician. None of the horses had more than one limb affected. Hindlimbs were significantly more often affected than the forelimbs (P<0.05). Thoroughbreds were significantly over-represented compared with the general distribution of breeds examined at the hospital. Blunt limb trauma, limb surgery and limb injections were associated with the cellulitis in most of the horses, but no plausible cause could be determined in 27 (43 per cent) of the cases. Staphylococcus aureus and Streptococcus species were frequently isolated, although mixed bacterial infections were also common. All the horses were treated with broad spectrum antimicrobials and non-steroidal anti-inflammatory agents, and ultrasound-guided surgical drainage was also applied in 14 cases. Fifty-six of the 63 horses (89 per cent) were discharged from the hospital. Laminitis affecting the contralateral limb was the most common reason for the euthanasia of the other seven horses.     

Morphological variations of the infraorbital canal during CT has limited association with headshaking in horses

Headshaking is a common problem in horses. The etiology is unknown but thought to involve sensory input from branches of the trigeminal nerve, some of which are within the infraorbital canal. The objective of this retrospective cross‐sectional study was to describe the CT anatomy and variations of the infraorbital canal in horses with local disease processes and normal horses, and to examine associations between those findings and headshaking. Computed tomography scans were reviewed and morphological changes of the infraorbital canal were described. Presence of changes was then tested for association with headshaking prevalence, presence of disease processes in the region of the infraorbital canal, age, and sex. Nonparametric tests were used and a P‐value of .05 was considered significant. A total of 218 horses were included, 9% of which had headshaking and 45% had CT lesions in the region of the infraorbital canal. Morphological changes to the bone of the infraorbital canal were found in 121 horses (56%) and included the following: increased mineralization 39 (18%), decreased mineralization 89 (41%), deformed shape 51 (23%), displaced position 43 (20%), and disruption 11 (5%). All changes of the infraorbital canal significantly increased in frequency with the presence of adjacent disease. Increased mineralization and disruption of the infraorbital canal were significantly associated with headshaking in horses with adjacent disease; the latter only reached significance after exclusion of dentally immature horses. No other changes were significantly associated with the presence of headshaking. No association was found between headshaking and the age or sex of the horse.     

Caudal compression of the infraorbital nerve: A novel surgical technique for treatment of idiopathic headshaking and assessment of its efficacy in 24 horses

Reasons for designing and reporting technique: Idiopathic headshaking has remarkable similarities to human neuropathic facial pain syndromes associated with post herpetic and trigeminal neuralgia. These derive from abnormal sensory function within the peripheral or central pathways of the trigeminal nerve (TgN). Limiting input from the TgN can be helpful in controlling the perception of pain. Rhizotomy of the infraorbital branch of the TgN as it emerges from the infraorbital canal has been reported but has a poor efficacy. A novel technique involves compression of the nerve at a more caudal location within the infraorbital canal and the technique requires validation. Hypothesis: Caudal compression of the infraorbital nerve with platinum coils, performed in horses diagnosed with idiopathic headshaking, results in a decrease in clinical signs. Methods: Caudal compression of the infraorbital nerve, using platinum embolisation coils, was performed under fluoroscopic guidance. Clinical records of 24 idiopathic headshakers that had undergone this procedure were reviewed. Follow‐up information was obtained by telephone questionnaire with the owner or referring veterinary surgeon. Results: All 24 horses had at least one surgical procedure. Median follow‐up time was 6 months. There were 2 horses which had surgery 2 weeks before follow‐up and these were excluded from the analysis of outcome. Following one surgery, 13/22 horses (59.0%) had a successful outcome. Of the 9 horses that did not improve, surgery was repeated in 6 cases. Two of these horses had a successful outcome. Overall, a successful outcome was obtained in 16/19 horses (84.2%). Conclusions: This surgical technique is likely to prevent input from the TgN at a more caudal location then the previously described infraorbital neurectomy. The technique requires refinement.     

Factors associated with the wastage and achievements in competition of event horses registered in the United Kingdom

The aims of this study were to estimate the wastage of horses registered for eventing in Britain, to investigate the reasons for this wastage and to evaluate factors affecting the horses' achievement of grade I status (at least 61 points) while registered. An analysis of the database of the British Eventing register found that 33.7 per cent of horses registered for the first time in 1999 were not re-registered for eventing in subsequent years. By using multivariable logistic regression analysis, it was shown that horses that were kept at an event yard were more likely to be re-registered than those kept on other premises (odds ratio [or] 2.0, 95 per cent confidence interval [ci] 1.2 to 3.2), and those that took part in showjumping while registered were also more likely to be re-registered (or 1.5, 95 per cent ci 1.1 to 2.2). Horses that took part in unaffiliated eventing while registered were less likely to be re-registered the following year (or 0.7, 95 per cent ci 0.5 to 0.9), as were those that were not insured (or 0.7, 95 per cent ci 0.5 to 1.0) and those from outside the British Isles (or 0.6, 95 per cent ci 0.3 to 1.0). Veterinary problems were the most commonly cited explanation (35.1 per cent) why horses that remained in their original ownership were not re-registered with British Eventing the following year. Horses from Australia were more likely to achieve grade I status than horses from the British Isles (or 9.7, 95 per cent ci 7.1 to 13.2), as were horses from New Zealand (or 6.4, 95 per cent ci 5.0 to 8.2), the usa (or 5.2, 95 per cent ci 3.8 to 7.2) and France (or 2.8, 95 per cent ci 2.1 to 3.7), but horses from the Netherlands (or 0.5, 95 per cent ci 0.3 to 0.9) and Belgium (or 0.3, 95 per cent ci 0.1 to 0.9) were less likely to achieve grade I status. Mares were less likely to achieve grade I status than geldings (or 0.4, 95 per cent ci 0.4 to 0.5).